1st English Case Report To whom respectfully

dr. Utari Gustiany Dr …………………………………..

BRONCHIECTASIS CAUSED BY LUNG TUBERCULOSIS

Introduction
Bronchiectasis is a chronic respiratory disease that causing cough, sputum production,
and frequent chest infections leading to poor quality of life and high health-care
resource utilization. Bronchiectasis is defined as permanent and abnormal dilation of
the bronchi caused by the destruction of the elastic and muscular components of the
bronchial wall. It is a frequent consequence of pulmonary tuberculosis infection, with
a systematic review suggesting about 40% of survivors of tuberculosis infection
develops radiological bronchiectasis.1
Bronchiectasis is commonly caused by recurrent or severe respiratory
infections such as pneumonia (both bacterial and viral), tuberculosis, adenovirus,
measles and pertussis. It may also be associated with; congenital syndromes and
abnormalities, chronic obstructive pulmonary disease (COPD), gastro-oesophagal
reflux, smoking and passive smoking, mucociliary dysfunction, immune deficiency,
pulmonary fibrosis, post-obstruction (e.g. with an unrecognized foreign body),
recurrent aspiration and systemic inflammatory diseases (e.g. rheumatoid arthritis,
sarcoidosis). Overcrowding and socioeconomic deprivation are also important
contributing factors.2
The true disease burden from bronchiectasis in children is difficult to ascertain
as the diagnosis is often delayed and depends upon the populations studied, physician
awareness, and availability of radiology findings. The national incidence of
bronchiectasis in children aged 0–14 years living in affluent countries is considered
low and ranges from 0.5 per 100,000 child-years in Finland 9 to 3.7 per 100,000 child-
years in New Zealand.3
Bronchiectasis is a clinical syndrome coupled with distinct radiological
findings on CT scan of the chest. Although the clinical presentation can vary, chronic

1
productive cough is almost universally present. However, the chronic cough can
resolve on treatment in early (i.e. cylindrical) bronchiectasis. Patients may have chest
signs on auscultation such as wheezing and/or crepitations. The most frequent cause of
bronchiectasis was post-infectious (20%), COPD-related bronchiectasis (15%),
connective tissue disease-related (10%), immunodeficiencies (5.8%) and asthma-
related bronchiectasis (3.3%).4
The aim of this case presentation is to highlight the distinctive manifestation of
bronchiectasis caused by lung tuberculosis.

Case Report
A 16 years old boy was hospitalized in Dr. M. Djamil Hospital pediatric ward from
October 12th until October 18th 2019.
Chief complain: Bloody cough since four days ago

Present Illness History

There was bloody cough for four days before admission, presented with mucous, 1¼
glass, the colour of the blood was bright-red. Patient has productive chronic cough
since more than nine months ago, worsening this one month.There was no
breathlessness. There was no fever, nor seizure. There was no sign of bleeding on the
gums, nose, and digestive system. There was a slight loss of appetite, but without
weigth loss, weight gain occurred from 36 kg to 47 kg instead. No history of trauma
nor usage of anticoagulant drugs. No history of asthma and not a smoker. No
abnormalities in urination and defecation. The patient suffered from lung tuberculosis
since December 2018 and had finished his 9 months of anti-TB agents in September
2019. The patient had BCG immunization, scar (+) on the left arm.
The patient was referred from a private hospital in Pasir Pengaraian with
repeated massive hemoptysis due to history of tuberculosis with differential diagnosis
of bronchiectasis and pulmonary mycosis. The patient had been given therapy
consisted of Meropenem 1 gr/8 hours, Tranexamic acid 1 amp/8 hours, Vitamin C 1

2
amp/8 hours, Vitamin K 1 amp/8 hours, Levofloxacin 750 mg/ 24 hours intravenous,
and Codeine 2x1 tab.

Past Illness History

The patient suffered from lung tuberculosis since December 2018 and had finished his
9 months of anti-TB drugs (fixed dose combination) in September 2019. The diagnosis
was determined from the radiology and Acid Fast Bacillus (AFB) test.

Family Illness History

There was no family history who suffered from tuberculosis and malignancy.

History of Delivery, Immunization and Development

The patient was the first child of two siblings, was born with spontaneous vaginal
delivery assisted by a midwife, was a term birth with a birth weight of 3500 gram and
birth length of 47 cm. Basic immunization was completed according to the Public
Health Programme. The patient had BCG immunization, scar (+) on the left arm.
Growth and developmental history were normal. The hygiene and sanitation condition
were quite good.

Family and Social Economy History

Her mother was a 41 years old woman, graduated with a bachelor degree, and was a
civil servant. Her father was a 43 years old male, graduated with a bachelor degree, and
a self-employed person with an income of approximately Rp. 3.500.000,00/month.
Patient and her family lived in their own home, a permanent house with good hygiene
and sanitation.

Physical examination
The patient seemed moderately ill with a blood pressure of 120/80 mmHg (P50 117/73
mmHg, P90 131/88 mmHg, P95 135/92 mmHg, P99 142/100 mmHg), heart rate was 88
times per minute, respiratory rate was 22 times per minute, body temperature was

3
36.9oC, body weight was 47 kg, body height was 162 cm, weight for age was 73%,
height for age was 92%, weight for height was 95% (well-nourished). There was no
anaemic and no oedema, no jaundice and no cyanotic. The skin was warm. There was
no regional lymph enlargement. His head was round and symmetric, the conjunctivae
were not anaemic, sclerae were not icteric, and the pupils were isochors with a diameter
of 2mm/2mm, the light reflexes were positive normal. Ears and nose were normal.
Tonsils were T1-T1, not hyperemic and the pharynx was not hyperemic. Mucous in the
mouth was wet, no oral thrush, no mucosal ulcer. Jugular venous pressure (JVP) was
5-2 cmH2O. The chest was symmetric, no retraction. Phremitus was same on both of
lung, vesicular breath sounds, with rales in hemithorax dextra, and there was no
wheezing. The heart’s apex wasn’t visible. The apex was palpable at 1 finger medially
to the left midclavicular line, intercostal space V. The the heart’s position was as
follows: superior part of the heart was RIC II, the right border was the right sternalis
line, the left border was 1 finger medially to the left midclavicular line. The heart’s
sound was regular rhythm. There was no abdominal distension. The liver was not
palpable and the spleen also was not palpable, meanwhile the peristaltic sound was
normal. There was no abnormality found in genitalia, the puberty state was A3P3G3.
Extremities were warm with good perfusion, there was no clubbed finger.The
physiological reflexes were positive normal at the left and right side, and no
pathological reflexes.

Laboratory findings:
Hematology
Haemoglobin of 14 gr/dL, white blood cells of 10.320/mm 3, differential count were
0/2/0/67/27/4 %, hematocrit of 41 %, platelets of 356.000/mm 3, red blood cell of
5,38x106/mm3.

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 Figure 1. Rontgen thorax
List of Problems
1. Hemoptysis
2. History of pulmonary TB

Working Diagnosis
Hemoptysis ec susp pulmonary TB relaps dd/ Multidrug-resistent tuberculosis
Bronchiectasis
Mycoplasma
Malignancy

Management
1. Hemoptysis ec susp pulmonary TB relaps dd/ MDR-TB, bronchiectasis,
mycoplasma, malignancy
a. Diagnostic
History taking, physical examination, laboratory findings, rontgen thoraks
b. Therapy
Anti Tuberculosis drugs : FDC 1x 3 tabs, Vitamin B6 1 x 10 mg

5
 c. Education
The parents were given information about the diagnosis, management,
complication, and prognosis of the diseases.
d. Planning
TB work up : AFB test, culture of MTB, Xpert MTB/RIF Assay
Sputum fungal culture
HIV rapid test
Chest CT-Scan with contras
Consult to Pulmonary Departement

Pediatric Nutritional Care

1. Assessment
Body Weight : 47 kg
Body Height : 162 cm
Ideal Body Weight : 49 kg
Height Age : 13 years
CDC
Body Weight/Age : 73 %
Body Height/Age : 92 %
Body Weight/Body Height : 95 %
Nutritional Status : Well nourished
2. Requirement
RDA : 50 kkal/kgbw/day
Calorie per day : Ideal BW x RDA = 45 x 50 kcal = 2250 kcal
BMR = (16,25 W + 137,2 H + 515,5) = 1493,28 kcal
Stress factor : 1,2
Basal energy expenditure (BEE) = BMR x stress factor = = 1596,38
Fluid requirement: 50-60 ml/kgbw/day = 2350 cc - 2820 cc
Type of food : Regular food
Route : oral

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FOLLOW UP
The 2nd – 4th day of hospitalization (Oct 13th – 15th, 2019)
Fever wasn’t present. There was a phlegmy cough with hemoptysis, decreased than
before. There was no breathlessness, vomiting, nor chest pain. The patient had a good
appetite with good tolerance of food. Micturition and defecation were in normal limit.
The general appearance was moderately ill. The child was alert, compos mentis, and
cooperative. Blood pressure was 120/70 mmHg, heart rate was 92 x/minutes,
respiratory rate was 20 x/minutes, body temperature of 36,8˚C, and there was no
cyanosis. The conjunctiva was not anemic, sclera was not icteric. The pupils were
symmetrical with a diameter of 2/2 mm, the light reflexes were normal. The chest was
symmetric, no retraction. Phremitus was same on both of lung, vesicular breath sounds,
with rales in hemithorax dextra, and there was no wheezing. The heart was at regular
rhythm, with no murmur. The abdomen was not distended, and the liver was not
palpable. The spleen was not palpable. The abdomen was tympanic on percussion, with
normal bowel sounds on auscultation. Extremities were warm and refilling capillary
time was normal, there was no clubbed finger. Result of Xpert MTB/RIF Assay: MTB
not detected, anti-HIV Rapid Test: not reactive, AFB test I and II : negative.
Impression: Hemoptysis ec pulmonary TB dd/ Bronchiectasis, mycoplasma,
malignancy.
The managements were a regular meal 2000 kcal and Inj. Tranexamic Acid 3x1
amp iv, FDC 1x3 tab po, and Vitamin B6 1 x 10 mg.

The 5th day of hospitalization (Oct 16th, 2019)

The phlegmy cough with hemoptysis was decreased. There was no breathlessness,
vomiting, nor chest pain. The patient had a good appetite with good tolerance of food.
Micturition and defecation were in normal limit. The general appearance was
moderately ill. The child was alert, compos mentis, and cooperative. The blood
pressure was 110/70 mmHg, heart rate was 84 x/minutes, respiratory rate was 20
x/minutes, and body temperature of 37,0˚C, with no cyanosis. The conjunctiva was
not anemic, sclera was not icteric. The pupils were symmetrical with a diameter of 2/2

7
mm, the light reflexes were normal. The chest was symmetric, no retraction. Phremitus
was same on both of lung, vesicular breath sounds, with rales in hemithorax dextra,
and there was no wheezing. There were rales on auscultation. The heart was at regular
rhythm, with no murmur. The abdomen was not distended, and the liver was not
palpable. The spleen was not palpable. The abdomen was tympanic on percussion, with
normal bowel sounds on auscultation. Extremities were warm and refilling capillary
time was normal, there was no clubbed finger. Impression: Hemoptysis ec pulmonary
TB dd/ Bronchiectasis, mycoplasma, malignancy.
The managements were a regular meal 2000 kcal and Inj. Tranexamic Acid 3x1
amp iv, FDC 1x3 tab po, and Vitamin B6 1 x 10 mg. Consult to Pulmonologist for
bronchoscopy.

The 6th day of hospitalization (Oct 17th, 2019)

There was a phlegmy cough with no hemoptysis. There was no breathlessness,
vomiting, nor chest pain. The patient had a good appetite with good tolerance of food.
Micturition and defecation were in normal limit. The general appearance was
moderately ill. The child was alert, compos mentis, and cooperative. The blood
pressure was 110/70 mmHg, heart rate was 88 x/minutes, respiratory rate was 20
x/minutes, the body temperature of 36,8˚C, with no cyanosis. The conjunctiva was not
anamic, sclera was not icteric. The pupils were symmetrical with a diameter of 2/2 mm,
the light reflexes were normal. The chest was symmetric, no retraction. Phremitus was
same on both of lung, vesicular breath sounds, with rales in hemithorax dextra, and
there was no wheezing. There were rales on auscultation. The heart was at regular
rhythm, with no murmur. The abdomen was not distended, and the liver was not
palpable. The spleen was not palpable. The abdomen was tympanic on percussion, with
normal bowel sounds on auscultation. Extremities were warm and refilling capillary
time was normal, there was no clubbed finger. Impression: Hemoptysis ec pulmonary
TB dd/Bronchiectasis, mycoplasma, malignancy
The managements were a regular meal 2000 kcal, stop Tranexamic Acid 3x1
amp iv, FDC 1x3 tab po, and Vitamin B6 1 x 10 mg.

8
 The Pulmonologist consultation results were hemoptysis due to suspected
Bronchiectasis and advised to continue anti TB drugs for 3 months, culture MTB, and
chest CT scan with contras. Broncoschopy was prepared after chest CT scan was
performed.

The 7th day of hospitalization (Oct 18th, 2019)

There was a phlegmy cough with no hemoptysis. There was no breathlessness,
vomiting, nor chest pain. The patient had a good appetite with good tolerance of food.
Micturition and defecation were in normal limit. The general appearance was
moderately ill. The child was alert, compos mentis, and cooperative. The blood
pressure was 110/70 mmHg, heart rate was 82 x/minutes, respiratory rate was 20
x/minutes, and the body temperature of 36,8˚C, with no cyanosis. The conjunctiva was
not anamic, sclera was not icteric. The pupils were symmetrical with a diameter of 2/2
mm, the light reflexes were normal. The chest was symmetric, no retraction. Phremitus
was same on both of lung, vesicular breath sounds, with rales in hemithorax dextra,
and there was no wheezing. The heart was at regular rhythm, with no murmur. The
abdomen was not distended, and the liver was not palpable. The spleen was not
palpable. The abdomen was tympanic on percussion, with normal bowel sounds on
auscultation. Extremities were warm and refilling capillary time was normal, there was
no clubbed finger. Impression: Hemoptysis ec pulmonary TB dd/ Bronchiectasis,
mycoplasma, malignancy.
The managements were a regular meal 2000 kcal, FDC 1x3 tab po, and Vitamin
B6 1 x 10 mg. Work up planned the patient was planned to be discharged. The follow-
up outpatient planning was to run a chest CT Scan with contras at the out patient clinic.

The 1st Outpatient (Pediatric Clinic) Follow Up (Oct 22nd, 2019)

There was phlegmy cough without hemoptysis. There was no breathlessness, vomiting,
nor chest pain. The patient had a good appetite with good tolerance of food. Micturition
and defecation were in normal limit. The general appearance was moderately ill. The
child was alert, compos mentis, and cooperative. The blood pressure was 110/70

9
mmHg, heart rate was 80 x/minutes, respiratory rate was 19 x/minutes, and the body
temperature of 36,8˚C, with no cyanosis. The conjunctiva was not anemic, sclera was
not icteric. The pupils were symmetrical with a diameter of 2/2 mm, the light reflexes
were normal. The chest was symmetric, no retraction. Phremitus was same on both of
lung, vesicular breath sounds, with rales in hemithorax dextra, and there was no
wheezing. The heart was at regular rhythm, with no murmur. The abdomen was not
distended, and the liver was not palpable. The spleen was not palpable. The abdomen
was tympanic on percussion, with normal bowel sounds on auscultation. Extremities
were warm and refilling capillary time was normal, there was no clubbed finger. Result
from culture fungal of sputum was no growth. Impression: Pulmonary TB dd/
Bronchiectasis, malignancy.
The managements were continuing FDC treatment 1x3 tab PO, and Vitamin B6
1 x 10 mg. Thorax CT scan was scheduled on Oct 24th, 2019. We still waited for the
results of the culture of MTB from sputum (it took approximately 2-3 months to
complete the culture of MTB in our center).

The 2nd Outpatient (Pediatric Clinic) Follow Up (Dec 24th, 2019)

There was no phlegmy cough, nor hemoptysis. No breathlessness, vomiting, nor chest
pain. The patient had a good appetite with good tolerance of food. Micturition and
defecation were in normal limit. The general appearance was moderately ill. The child
was alert, compos mentis, and cooperative. The blood pressure was 120/80 mmHg,
heart rate was 78 x/minutes, respiratory rate was 20 x/minutes, and the body
temperature of 36,7˚C, with no cyanosis. The conjunctiva was not anemic, sclera was
not icteric. The pupils were symmetrical with a diameter of 2/2 mm, the light reflexes
were normal. The chest was symmetric, no retraction. Phremitus was same on both of
lung, vesicular breath sounds, and there was no wheezing, there were no more rales on
auscultation. The heart was at regular rhythm, with no murmur. The abdomen was not
distended, and the liver was not palpable. The spleen was not palpable. The abdomen
was tympanic on percussion, with normal bowel sounds on auscultation. Extremities
were warm and refilling capillary time was normal, there was no clubbed finger. The

10
result of the culture of MTB was no growth. The chest CT-Scan at the Policlinic
showed Pulmonary TB with Bronchiectasis (Fig. 2). Impression: Bronchiectasis
improved by pulmonary TB treatment. The managements were continuing FDC
treatment 1x3 tab PO to complete the 12-months-treatment regiment, and Vitamin B6
1 x 10 mg.

Figure 1. Chest CT Scan: Pulmonary TB with Bronchiectasis.

Chest CT scan with IV contrast showed the appearance of bronchiectasis with irregular
shape in the superior lobe, 6th segment, and minimal in the medial lobe of the right
lung with pulmonary fibrous infiltrate. There was no crescent sign appeared

11
LITTERATURE REVIEW

TUBERCULOSIS
Definition
Tuberculosis has been known for many centuries and is caused by the bacillus
Mycobacterium tuberculosis, a member of the mycobacterium family. It has made a re-
emergence in recent decades to such an extent that in 1993 the World Health
Organisation declared tuberculosis as a ‘global emergency’.5 The mode of transmission
in humans is by inhalation of infected aerosol droplets, and usually causes disease in
the lungs. However, any system in the body may be affected. Only the pulmonary form
is infectious.6 Conversely, it is now becoming clearer that TB itself may lead to chronic
respiratory disease, particularly bronchiectasis and COPD.7,8

Epidemiology
Tuberculosis in children is increasingly being recognized as a significant public health
problem, and an important component of the total global burden of tuberculosis. 9
Among the 4,452,860 new cases reported in 2010 by the 22 countries with the highest
burden of disease from tuberculosis, only 157,135, or 3.5% (range, 0.1 to 15.0), were
in children. Best estimates suggest that children (defined as persons younger than 15
years of age) account for approximately 11% of the burden of disease from
tuberculosis, suggesting that just over 332,000 cases of tuberculosis in children went
undiagnosed or unreported in these countries. Although overdiagnosis does occur,
underdiagnosis is the rule in most areas where there is a high burden of disease and
children with tuberculosis can access services only through referral hospitals. The
problem of underdiagnosis in children is illustrated by the low pediatric caseload
reported in four countries with a high disease burden, where rates exceeding 10% of
all reported cases would be expected: Russia, 0.8%; India, 1.1%; Nigeria, 1.4%; and
Brazil, 3.5%.5,10

12
Etiology and Pathogenesis
Although much remains unknown about its pathophysiology, TB studies characterized
a dynamic continum of various states that include exposure, infection, subclinical or
incipient disease, non-severe and severe disease states.11,12 Generally, this continuum
correlates with bacterial burden. As the archetypical human pathogen, Mycobacterium
tuberculosis establishes a sustained but “delicately balanced” host–pathogen
relationship.13 These TB states depend upon various host (e.g. immunological
competence), pathogen (e.g. strain virulence), and environmental (e.g. intensity of
exposure) factors. The clinical outcome of infection will thus be either self-cure,
latency or disease.14 Understanding that TB is a continuum of states—and not a
dichotomy of infection or disease—has important implications for managing children
in whom latent or active TB often cannot be confirmed. 15
Once infected with M. tuberculosis, young children (aged <5 years) are at
greater risk than adults of progressing to disease, including its most severe forms. This
depends on the child’s susceptibility, which is highest during the first years of life,
probably from immunological immaturity. Without Bacille Calmette-Guerin (BCG)
vaccination, approximately 30% of infected infants (<1 year old) will progress to
intrathoracic TB, and 10–20% will develop disseminated disease. In children aged 1–
2 years, the risk of progressing to intrathoracic TB is 10–20 and 2–5% for disseminated
disease. These risks decline slowly until around 10 years of age when adult-type disease
starts to emerge. Thus, early diagnosis is important, especially in infants and young
children who are at greatest risk of rapid disease development and clinicians should
consider the full clinical spectrum of intrathoracic syndromes. 15

Diagnosis
Children are usually evaluated for tuberculosis after presenting with symptoms or signs
suggestive of disease (passive case finding) or as a result of contact investigation or
routine immigration screening (active case finding). The clinical presentation of
children whose infection is detected through active case finding differs from that of
children whose infection is detected through passive case finding, with the former

13
group often having infection but not disease or having disease in a very early phase.
Among children in whom M. tuberculosis infection is detected, young children and
those with recent exposure are at increased risk for progression to disease. Knowledge
of the child’s status regarding the likelihood of exposure changes the pretest probability
of disease and the positive predictive value of subsequent investigations. 10
Taking a careful patient history is essential for exploring the nature of the
exposure and accurately characterizing the symptoms. The diversity of the clinical
presentation and the nonspecific nature of most symptoms complicate diagnosis.
Constitutional symptoms often include failure to thrive (deviation from the expected
growth-curve trajectory) and reduced playfulness; low-grade or intermittent fever is
seen less frequently. With airway involvement, the usual presenting symptom is a
persistent, non-remitting cough or wheeze that is unresponsive to the treatment for
likely alternative causes. Clinical signs are often subtle, and no diagnostic scoring
system has been adequately validated; the sensitivity and specificity of the clinical
diagnostic approaches for tuberculosis are particularly poor in children with HIV
infection.10,16
In clinical practice, chest radiography is one of the most useful diagnostic
studies. Both frontal and lateral views should be obtained, since a lateral view assists
in the assessment of the mediastinal and hilar areas. The radiographic findings vary,
but pronounced hilar adenopathy, with or without airway compression, is highly
suggestive of tuberculosis. The International Union against Tuberculosis and Lung
Disease compiled an atlas of illustrative cases. Unfortunately, the technical quality of
the radiographs obtained in areas where tuberculosis is endemic is often poor or
radiographic facilities are not available.10
Ultrasonography is useful in confirming the presence of pericardial or pleural
effusions and abdominal lymphadenopathy. High-resolution computed tomography
(CT) offers excellent anatomical visualization, but because of the high cost of CT and
the high level of radiation to which the patient is exposed, as compared with other
forms of imaging, it should be reserved for complicated cases. 10,17

14
 Microscopical examination of sputum smears is the cornerstone of diagnosis in
most countries, but its usefulness is limited in young children with paucibacillary
disease who are unable to expectorate. Both the tuberculin skin test and the interferon-
γ release assay fail to differentiate M. tuberculosis infection from active disease. The
WHO recommends that the assay not be used in place of the tuberculin skin test,
although the two tests may be complementary, improving the sensitivity or specificity
of the assessment in specific clinical circumstances. 5,10

Management
The purpose of tuberculosis treatment is to cure the individual patient, whereas the
intent of public health efforts is to terminate transmission and prevent the emergence
of drug resistance. Rapidly metabolizing bacilli are quickly killed by bactericidal
agents with high activity, thereby terminating transmission, ameliorating symptoms,
and decreasing the risk of drug resistance (by reducing the population from which drug-
resistant mutants emerge). The use of drugs with sterilizing activity is required to
eradicate persistent subpopulations of intermittently metabolizing bacilli, thereby
preventing relapse and effecting along-term cure.5,10
The most important variables to consider in disease management are bacillary
load and anatomical location. Drug resistance should be considered in children from
areas with a high prevalence of drug-resistant tuberculosis and in those who have had
documented contact with a person with drug-resistant disease, with someone who died
during treatment for tuberculosis or who is not adhering to therapy, or with someone
who is undergoing retreatment for tuberculosis. Young children with uncomplicated
disease who are from areas with a low prevalence of isoniazid resistance can be treated
with three drugs (isoniazid, rifampin, and pyrazinamide) during the 2-month intensive
phase of treatment, followed by isoniazid and rifampin only during the 4-month
continuation phase. However, children who have extensive or cavitary lung disease
(either of which suggests a high bacillary load) or who are from areas with a high
prevalence of isoniazid resistance should receive a fourth drug (ethambutol, which is
safe in children of all ages) during the 2-month intensive phase of treatment. 5,10

15
BRONCHIECTASIS
Definition
Bronchiectasis is a progressive respiratory disease characterised by permanent
dilatation of the bronchi and associated with a clinical syndrome of cough, sputum
production and recurrent respiratory infections. It is a lung disease characterised by
irreversible bronchial dilation and chronic inflammation, resulting in chronic wet
cough. Recurrent cycles of infection and inflammation impair mucociliary clearance,
leading to progressive remodelling and scarring of the bronchial walls. Symptoms of
bronchiectasis are often present for many years before the diagnosis is made. 2,18,19
The true disease burden from bronchiectasis in children is difficult to ascertain as the
diagnosis is often delayed and depends upon the populations studied, physician
awareness, and availability of cHRCT scans with updated pediatric protocols.
Bronchiectasis can confer substantial potential morbidity, usually secondary to
recurrent infection. In severe cases of bronchiectasis, massive hemoptysis can lead to
death. Hemoptysis is a frequent symptom in adult patients with bronchiectasis, whereas
it is a relatively uncommon in pediatric patients. Thin-section computed tomography
is the most sensitive imaging modality for the detection of bronchiectasis, findings
include bronchial diameter exceeding that of the adjacent pulmonary artery and lack of
normal tapering of terminal bronchioles as they course toward the lung periphery. 3,19,20

Epidemiology
Bronchiectasis is a growing global health problem. In Europe and the USA the reported
prevalence of the disease has increased by more than 40% in the past 10 years. 21 It
occurs in every age group and, in the pre-antibiotic era, it most often began in
childhood. Among all ages, it has been estimated that about 25 people per 100,000 have
bronchiectasis, but this number increases to 272 per 100,000 for those over 74 years
old. Cases of bronchiectasis are more common in women than men, especially when it
is of unknown cause.
Bronchiectasis was traditionally defined as an irreversible dilatation of the
airways. However, as several studies in children have shown that mild (i.e. cylindrical)

16
bronchiectasis may be reversible when treated early and aggressively, it is now
generally accepted that bronchiectasis is a syndrome with a constellation of respiratory
symptoms (predominantly chronic wet/productive cough) together with CT evidence
of abnormal airway dilatation.22 The national incidence of bronchiectasis in children
aged 0–14 years living in affluent countries is considered low and ranges from 0.5 per
100,000 child-years in Finland, and 9 to 3.7 per 100,000 child-years in New Zealand.
However, among Aboriginal infants from Central Australia incidence rates reach 200
per 100,000 child-years. Similarly, although the prevalence of bronchiectasis in those
aged 0–14 years in New Zealand is 33 per 100,000; for Pacific Island children in New
Zealand it is 160 per 100,000 (10); in Canadian Inuit children in Banff region it reaches
200 per 100,000; while for Aboriginal children from Central Australia and South-West
Alaskan Native children rates are about 1,500 per 100,000. 3
Mortality from bronchiectasis also varies between populations. Of the 5,745
deaths attributed to bronchiectasis in England and Wales between 2001 and 2007, only
12 were in the 0–14 year age group.23 Pediatric bronchiectasis mortality data from
developing countries are limited, a Malaysian study observed considerable morbidity
with a negative impact upon growth, lung function, and quality of life (QoL). 24 Similar
adverse effects were observed in New Zealand Maori and Pacific Island children,
despite receiving treatment at a tertiary center while in contrast in children from
England treatment stabilized lung function. 25 Furthermore, bronchiectasis has been
associated with increased cardiac morbidity, malnutrition, osteopenia, and even
cancer.3

Etiology
Unlike adults, in whom bronchiectasis is most commonly reported as idiopathic,
aetiological factors are identified in more than 70% of some paediatric populations.
Identifying the underlying aetiology is important, as it allows individualized treatment
of a potentially irreversible disease process where early interventions are believed to
minimise long-term morbidity and mortality. Recent evidence suggesting that
radiological changes described in bronchiectasis may remain static, show improvement

17
or even completely resolve over prolonged periods of time could be due to the
beneficial effects of early aggressive treatment. 25
Bronchiectasis is commonly caused by recurrent or severe respiratory
infections such as pneumonia (both bacterial and viral), tuberculosis, adenovirus,
measles and pertussis. It may also be associated with; congenital syndromes and
abnormalities, chronic obstructive pulmonary disease (COPD), gastro-oesphageal
reflux, smoking and passive smoking, mucociliary dysfunction, immune deficiency,
pulmonary fibrosis, post-obstruction (e.g. with an unrecognised foreign body),
recurrent aspiration and systemic inflammatory diseases (e.g. rheumatoid arthritis,
sarcoidosis). Overcrowding and socioeconomic deprivation are also important
contributing factors.26,27

Pathogenesis and Pathophysiology

Until today the exact mechanisms leading to the development of bronchiectasis remain
poorly understood, although is believed to be related to persistent infection and
inflammation of the airways.28 Knowledge of the basic pathophysiological mechanisms
underlying the development of bronchiectasis is necessary in order to understand its
management. This involves an interplay between the host (airway and systemic)
inflammatory response, pathogens and the environment.29
Histologically, in bronchiectasis, the bronchial walls (elastic and muscular
components) become damaged by an acute or chronic insult (often infection) leading
to progressive bronchial wall dilatation and airflow obstruction. This kind of injury is
believed to initiate a vicious cycle phenomenon whereby muco-ciliary clearance is
impaired contributing to ongoing infection, inflammation and bronchial wall damage.
It has been suggested that pediatric bronchiectasis may be reversible when diagnosed
early and managed intensively.3,30
The vicious cycle hypothesis is related to the presence of a disease continuum.
It was postulated that protracted bacterial bronchitis (PBB), chronic suppurative lung
disease (CSLD) and bronchiectasis represent a clinical spectrum with increasing
severity.31 PBB is defined as presence of chronic wet cough (i.e. cough lasting >4

18
weeks), resolution of cough with 2 weeks appropriate antibiotic therapy and absence
of pointers to indicate an alternative cause for cough. CSLD is the term given to patients
who have the clinical characteristics of bronchiectasis but lack the diagnostic
radiological features. Children with >3 episodes of PBB per year and those with
H.influenzae lower airway infection appear to be at increased risk of bronchiectasis.
Further, chronic wet cough that fails to respond to a 4-week course of appropriate
antibiotics has been shown to predict bronchiectasis.32,33

Diagnosis
Bronchiectasis is a clinical syndrome coupled with distinct radiological findings on CT
scan of the chest. Although the clinical presentation can vary, chronic wet cough is
almost universally present. However, the chronic cough can resolve on treatment in
early (i.e. cylindrical) bronchiectasis. Patients may have chest signs on auscultation
such as wheezing and/or crepitations. Hemoptysis is rarely seen in children with
bronchiectasis in high income countries.22
Consider bronchiectasis in a child with chronic wet/productive cough lasting
longer than six weeks, especially between viral infections (N.B. if there is suspicion of
an inhaled foreign body, the child should have a chest x-ray after two weeks), wheeze
that does not respond to treatment, partial resolution of severe pneumonia or recurrent
pneumonia, persistent lung crackles, persistent x-ray changes, respiratory symptoms
with structural or functional disorders of the oesophagus and upper respiratory tract.
Other clinical features of bronchiectasis include dyspnoea, chest pain, clubbing,
hyperinflation or chest wall deformity and failure to thrive.26,27,34
Chest CT is the gold-standard imaging modality for the diagnosis of
bronchiectasis. The hallmark radiological feature is increased bronchoarterial ratio
(BAR) > 1 (as measured by inner luminal diameter of the bronchus divided by outer
diameter of its accompanying vessel). A cut-off of 0.8 is more appropriate for
children.22 Other radiological features seen in bronchiectasis (whilst not
pathognomonic) include: bronchial wall thickening, non-tapering of peripheral bronchi
and mosaic perfusion or air trapping (seen on expiratory images), air-fluid levels in the

19
airways and mucoid impaction. Tree in bud appearance is seen in the acute stages of
bronchiectasis. Bronchiectasis, previously defined as “irreversible” dilatation of the
airways, is now modified to a clinical syndrome with CT scan showing abnormally
dilated airways.33,35 Recent studies with High Resolution Computed Tomography
(HRCT) suggest mild (i.e. cylindrical) bronchiectasis can show radiological resolution,
especially if treated early. In contrast, varicose and cystic bronchiectasis are reflective
of more advanced disease and are usually irreversible. 22,30

Management
After a diagnosis of bronchiectasis is made and an underlying cause investigated, the
aim of treatment is to improve QoL, reduce frequency and/or severity of exacerbations,
prevent progression of disease and/or achieve resolution and minimize complications.
The justification for early and aggressive treatment of children with, or at risk of,
bronchiectasis is that it may preserve lung function and improve or reverse changes in
those with mild disease. 22,25
Regular airway clearance tailored to an individual child by a physiotherapist
with respiratory expertise is considered standard treatment for bronchiectasis. 36 There
are several different physiotherapy techniques, many of which are age-dependent.
Airway clearance techniques employed may include use of a device (e.g. an oscillatory
positive expiratory pressure (PEP) device), autogenic drainage, and/or manual
techniques such as chest percussion. Although there are no supportive studies on
optimal frequency of physiotherapy, daily airway clearance is generally recommended
with intensification during exacerbations.37
Antibiotic therapy is a key component in the management of patients with
bronchiectasis. This is based upon recognition of the role of bacterial infection in
bronchiectasis pathogenesis. Historically, there has been a paucity of research into
optimal antibiotic prescribing in bronchiectasis, although there has been a recent surge
in trials in this area, particularly in adults.38
Bacterial load is directly related to neutrophilic airway inflammation in children
with bronchiectasis. The aim of antimicrobial therapy is to reduce pathogen load and

20
attenuate the infection-inflammation cycle. Antibiotics reduce morbidity and the risk
of exacerbations while also improving QoL in adults with bronchiectasis. Antibiotic
selection is based upon many factors including known or presumed lower airway
pathogen, patient factors, e.g. age and severity of lung disease and clinical response to
therapy.22,39
However, there are inherent challenges in antimicrobial prescribing for
bronchiectasis in children. As most young children are unable to produce sputum,
pathogen identification and susceptibilities are often unknown. CF studies have shown
that upper airway sampling is a poor predictor of lower airway microbiota and is thus
not routinely used in children with bronchiectasis unrelated to CF. 40 Lower airway
sampling via bronchoalveolar lavage (BAL) is relatively invasive and generally
undertaken at the time of diagnosis and later reserved for children who are
nonresponsive to empiric antibiotics. Where possible, sputum induction should be
used. However, in the absence of knowledge of an individual child’s lower airway
bacteriology, empirical antibiotic selection is frequently employed.22
Exacerbations of bronchiectasis invariably occur during followup.
Exacerbations are important as they impact on QoL and are associated with financial
cost. Further, frequency of exacerbations requiring hospitalization predicts future lung
function decline in childhood which is also seen in adult patients. Aggressive and
timely therapy for exacerbations, with antibiotics and airway clearance, helps to
preserve lung function into adulthood. 22,41
Macrolides act as both antimicrobial and anti-inflammatory agents. In
simplistic terms, macrolides attenuate host inflammatory responses providing an anti-
inflammatory effect without immune system suppression. Their anti-inflammatory
effects range from inhibition of biofilm production to modulation of leukocyte
recruitment and function. The rationale for their use in bronchiectasis is based upon
attenuation of the inflammatory component of the vicious cycle. 22
Mucoactive agents aim to assist in mobilizing airway secretions to relieve small
and large airway obstruction and/or reduce mucus hypersecretion. There are different
types of mucoactive medications. These are generally divided into expectorants,

21
mucoregulators, mucolytics, and mucokinetics. There is possibly some benefit
associated with using expectorants such as inhaled hyperosmolar agents. Earlier studies
suggested a benefit in assisting mucous clearance in patients with impairment of muco-
ciliary function and in an animal study.31
Nonsteroidal anti-inflammatories (NSAIDs), such as indomethacin, inhibit
neutrophil function and chemotaxis and may reduce neutrophil elastase release thus
potentially reducing progression of bronchiectasis. There is limited evidence that
NSAIDs may be beneficial in adults with pediatric bronchiectasis. A Cochrane review
examining nebulized NSAIDs included a single study in adults that showed inhaled
indomethacin reduces sputum production and dyspnea in adults with chronic lung
diseases characterized by chronic sputum production (including bronchiectasis). 22
In a small highly select group of children with localized severe disease, who
either do not tolerate conventional therapies or fail to respond surgical evaluation for
lobectomy or segmental lung resection may be appropriate. The evaluation is usually
undertaken in specialized, tertiary care facilities involving respiratory and infectious
diseases consultation. A retrospective study of 54 children undergoing open lung
resection for bronchiectasis, found that most benefitted from surgery (approximately
85%) although the mortality rate was high (5.6%) from open surgery. 22

Outcome
Children with bronchiectasis should be monitored and assessed every 3-6
months, ideally with a multidisciplinary team. Monitoring should also include
assessment of growth and development as these are important clinical indicators of
severity. Spirometry is routinely performed in children >6 years and management is
usually escalated if there is a progressive decline in FEV1 over time. However,
spirometry is an insensitive marker of bronchiectasis (spirometry may be normal even
in presence of radiological bronchiectasis), and does not exclude its presence. Lung
volumes are often performed at diagnosis and repeated at varying intervals e.g. yearly.
Sputum cultures should be regularly obtained.26,42 The decision to use imaging is
clinician-dependent. Chest X-ray is insensitive and not suitable for monitoring.

22
 Monitoring with CT chest imaging carries the risk of radiation exposure. It is
generally reserved for patients where clinical suspicion of disease progression is
present and when management decisions may be impacted. Chest MRI, whilst only
used in research settings currently, shows promise as a future imaging modality in
bronchiectasis. Functional assessments may include the 6-minute walk or modified
shuttle tests. Other management and investigations are tailored to the individual. 22

23
CASE ANALYSIS
This was a case report of a 16 year-old boy diagnosed with hemoptysis due to
bronchiectasis due to lung tuberculosis. Diagnosis was based on anamnesis, physical
examination, and radiology findings. The patient had coughed up blood, history of
previous pulmonary TB, and history of chronic cough before TB treatment. On
physical examination, we found rales in thorax examination. From the chest CT scan,
the picture is obtained pulmonary TB with bronchiectasis.
The association between pulmonary tuberculosis and bronchiectasis was first
noted by Laennec (the inventor of the stethoscope) in 1819 when he noticed crackles
in the lungs of patients with tuberculosis and pneumonia. This association was
supported by Grancher in 1878, who recognized bronchiectasis as a sequel to
pulmonary tuberculosis, which was later confirmed by several post‐mortem studies of
people who had died from tuberculosis.43,44 These studies found the incidence of
bronchiectasis to range between 19% and 65%, with a higher incidence in the fibroid
stage of the disease.44 Childhood studies suggest bronchiectasis associated with
tuberculosis is the result of protracted bronchial obstruction by compression from
enlarged hilar and interlobar lymph nodes or by infiltration of bronchial walls by
caseous lymph nodes.45 In the aetiology of bronchiectasis, pulmonary infections are a
significant cause accounting for approximately one‐third of cases. 46 The proportion
attributable to tuberculosis is highly variable, ranging from 1% to 32%.47 The cause is
unknown in a sizeable percentage of cases, in some series, in excess of 50%. Other
associations include cystic fibrosis, primary and secondary ciliary dyskinesia,
immunodeficiency syndromes and rheumatoid arthritis. 6 The importance of lung
damage after respiratory infections, such as pneumonia, pertussis, measles, and
tuberculosis, as a cause of bronchiectasis is difficult to estimate, but is still the most
20
common cause in developing countries. Lung damage related to TB is one of the
major contributors in the aetiology of bronchiectasis in South Asia and Eastern
Europe.48 A systematic review of 27 studies in Malawi that evaluated patients after
recovery from TB based on CT imaging reported bronchiectasis in 35–86% of
patients.49

24
 A cohort study in Taiwan in 2002-2016, comprised 15,729 adult patients with
bronchiectasis. Idiopathic (32%) was the most common cause, followed by post-
pneumonia (24%). Other causes included post-tuberculosis (12%), chronic obstructive
pulmonary disease (14%), asthma (10%), gastroesophageal reflux disease (2%) and
rheumatic diseases (2%).50
Cough and sputum production were the most common symptoms of
bronchiectasis.51 Hemoptysis is a frequent symptom in adult patients with
bronchiectasis, whereas it is a relatively uncommon in pediatric patients.52 In this case,
the patient was 16 years old, which was close to the young-adult age group, and he was
coughing phlegm with hemoptysis.
Depending on the underlying disease, hemoptysis is a result of several different
pathologic mechanisms. It is important to remember that the lung contains two separate
vascular systems: the pulmonary and the bronchial vessels. Hemoptysis can occur with
involvement of either. Vascular engorgement with erosion is one of the mechanisms of
hemoptysis. This occurs within the bronchial capillaries in the mucosa of the
tracheobronchial tree as a result of acute infection such as viral or bacterial bronchitis,
chronic infection such as bronchiectasis, or a toxic exposure such as cigarette smoke.
The shearing force of coughing can result in bleeding. Chronic cough with fever and
weight loss complicated by hemoptysis can be seen both in tuberculosis and
bronchiectasis, although the latter often has more marked sputum production.53
High-resolution computed tomography (HRCT) is considered the gold standard
for the diagnosis of bronchiectasis. 54 The chest CT scan with IV contrast of this patient
showed the appearance of bronchiectasis with irregular shape in the superior lobe, 6th
segment, and minimal in the medial lobe of the right lung with pulmonary fibrous
infiltrate. There was no crescent sign appeared. This is in line with the study from Kuo
et al. which showed that quantitatively, bronchiectasis has a predominance of the upper
lobe, both in patients with cystic fibrosis and in controls.55 This also in line with Sharif
et al. which stated that the majority of the cases with post TB bronchiectasis were
associated with either unilateral upper lobe or bilateral upper lobe bronchiectasis found
in 67.5% of patients and nearly 1/4th i.e. 24% of patients had diffuse unilateral disease

25
involving all lobes of a hemithorax.54 But this is different with the study from Dagli
which stated that bronchiectatic lesions are most commonly found in the lower lobes,
probably because mucociliary clearance is facilitated by gravity in the upper lobes. 56
In the other hand, study from Kim et al. showed that bronchiectatic lesions were
identified most commonly in the left lower lobe, followed by the right lower lobe and
left upper lobe.20
Bronchiectasis occurs frequently in association with pulmonary tuberculosis
and is caused primarily by tuberculous bronchitis. It is common in all types of
tuberculosis, especially in the fibroid lesion stage. It may occur with active tuberculosis
and become part of the tuberculous picture. It may also occur with inactive tuberculosis
and then present a distinct symptom complex. It is easy to diagnose. It is a relatively
benign disease and usually no special treatment is needed; but when it becomes severe,
44
pulmonary resection is the procedure of choice. The result of the Xpert MTB/RIF
assay of this case was MTB not-detected. This showed that the patient had inactive TB,
which in line with the definition of post-tuberculous bronchiectasis outlined above. 44,57
In the presence of inactive tuberculosis, bronchiectasis produces a definite
symptom complex. (The term "inactive" as here used means a healed lesion, no
pulmonary cavitation, and sputum negative for tubercle bacilli by all methods). In such
cases the chief symptoms are cough, expectoration, and hemoptysis. The cough and
expectoration are usually mild; most often hemoptysis takes the form of blood
streaking, rarely brisk hemorrhage. Other symptoms, such as dyspnea, are part of the
general picture-not related specifically to the local bronchial disease.44
If the bronchiectatic lesions are in the upper lobes, the amount of expectorated
material is surprisingly slight in relation to the extent of ectasia. In most such cases it
is less than an ounce daily. In about 75 per cent of the patients, the amount of sputum
is only about 10 to 20 per cent of the amount which would be expected if a similar
degree of bronchiectasis were present in the lower lobes. Actually, the direction of
bronchial drainage is more important than the lobar location of ectasia. If the dilated
bronchus is above the level of the tracheal bifurcation, drainage is downward and
therefore relatively little material is expectorated. The downward draining lesions are,

26
for the most part, those in the upper lobes, although occasionally lesions in the apices
of the lower lobes will drain downward. Patients with dilated bronchi which drain
upward will expectorate much more sputum. Upward draining ectatic lesions are those
in the lower lobes, the right middle lobe, the lingular branch of the upper lobe, and even
some in the anterior basal portions of the upper lobes. Abundant cough and sputum are
indicative of bronchiectasis in the dependent portions of the lungs or of superimposed
44
infection by other organisms than the tubercle bacillus. This information is in line
with this case’s patient, who had just a slight amount of sputum and hemoptysis, and
the patient’s chest CT scan showed upper lobe bronchiectasis, which could explain the
downward drainage of sputum.
The approaches to management fall into the following categories: general
approach and treatment of the specific underlying cause, education for patients and
parents of children with bronchiectasis, airway clearance (physiotherapy, exercise,
mucolytic and hyperosmolar therapies), airway drug therapy (bronchodilation and anti-
inflammatory), antibiotic therapy, surgical management, and management of
complications. 58
The stepwise management of bronchiectasis are mild (adequate hydration,
vaccination, antibiotic therapy for acute exacerbations, and specific treatment, if
available), moderate (prolonged or cyclic antibiotics, mucolytics bronchodilators, chest
physiotherapy, pulmonary rehabilitation, surgical resection, if focal), and severe (long-
term oxygen therapy, inhaled/oral corticosteroids, and lung transplantation). 58 But, in
cases in which tuberculosis is active, treatment should be directed primarily at the
tuberculosis.44
It should be noted that, at first, the patient was referred from a specialist in a
private hospital (secondary health care service) with repeated massive hemoptysis e.c.
history of tuberculosis with differential diagnosis of bronchiectasis and pulmonary
mycosis. The patient then came to Dr. M. Djamil Hospital (a tertiary health care
service) with a chief complaint of bloody cough for four days before admission,
presented with mucous, 1¼ glass, and the colour of the blood was bright red. The
patient suffered from Lung Tuberculosis since December 2018 and had finished his 9

27
months of FDC medication in September 2019. He had a slight loss of appetite and his
weight-for-age was 73%. There were no other abnormalities apart from those already
mentioned.
Although the Xpert MTB / RIF assay results were negative for MTB, we still
need to look at the patient's clinical conditions, sputum smear and culture. Phyu et al.
stated in their study that approximately 4–5% of smear + TB patients were GeneXpert.
59
In Indonesia, there is a scoring system for TB in children published by the Indonesian
Ministry of Health. TB scores above 6 (maximum score of 13), can lead to clinically
60
diagnose TB in children. Diagnosis of TB in children can not only be determined
bacteriologically, but the diagnosis can also be determined based on clinical conditions.
In this patient, there was a history of having TB disease and the patient had just finished
his treatment one month before admission to Dr M. Djamil Hospital. The patient had
finished his FDC treatment as the results of his latest sputum smear and culture at the
private hospital where he was treated for his TB, was negative for MTB.
When the patient came to Dr M. Djamil Hospital, one month after he finished
his FDC treatment, he had hemoptysis, which could lead to suspicion of relapse of TB
in this patient. In addition, the patient's family did not know for sure whether there was
contact between the patient and other people who might have active TB. Based on
clinical symptom, chronic coughed and his chest x-ray also showed suspicion of TB
(giving a score of 2 in the childhood TB scoring system). Thus, the patient had a TB
score of 2/13, which was not sufficient to make a diagnosis of clinical TB. However,
with the clinical symptoms mentioned above, it still led to suspicion of relapse of TB
in this patient.
The patient then was consulted to the pulmonology department at DR. M.
Djamil Hospital and based on clinical suspicion, the pulmonology consultant decided
to give back FDC treatment and to run a sputum smear and culture again. The results
of this sputum culture came out 3 months after the sample was taken. Thus, while
waited for these results to come, the patient continued to be treated with FDC on the
basis of his clinical symptoms that led to suspicion of TB relapse.

28
 In addition, to control his hemoptysis, he was given tranexamic acid. Moen et
al conclude that limited research on the use of TA for treatment of haemoptysis exists.
As aetiology of haemoptysis as well as the length of treatment, dosage and form of TA
administration varied between the studies, strong recommendations are difficult to
give. The current best evidence, however, indicates that TA may reduce both the
duration and volume of bleeding, with low risk of short-term thromboembolic
complications, in patients with bronchiectasis and haemoptysis.61
On the 5th-7th day of hospitalization, there was a clinical improvement of the
patient. His hemoptysis had reduced and ultimately there was no hemoptysis at all. He
also had an increase in appetite. Thus the patient was planned to be discharged off the
hospital with discharge managements FDC 1x3 tab po, and Vitamin B6 1 x 10 mg.
Work up planned was waiting result sputum culture of MTB and run a chest CT Scan
at the outpatient clinic.
On the outpatient follow up, there was a clinical improvement of the patient.
There was no cough, nor hemoptysis at all at the second appointment of outpatient
follow up. He also had an increase in appetite. The result of the Culture of MTB was
no MTB detected. The chest CT Scan at the outpatient clinic showed Pulmonary TB
with Bronchiectasis. Considering the effectiveness of the therapy and from the results
of chest CT scan, the treatment planned was continuing FDC treatment 1x3 tab to
complete the 12-months-treatment regiment, and Vitamin B6 1 x 10 mg.
It should be remembered that bronchiectasis in association with inactive
tuberculosis is a benign disease. However, if symptoms are severe (especially massive
hemoptysis) resection is the only cure. Thoracoplasty or other collapse therapy measure
may be of palliative value in controlling hemorrhage in cases in which resection is
contraindicated. 44

29
 EVIDENCE BASED MEDICINE

A. Clinical Question
What the most common etiologies of Hemoptysis in Children?

B. Component of foreground question (PICO)

Population/problem : Common etiologies of Hemoptysis in Children
Intervention : None
Comparator : None
Outcome : The majority of chidren who present with the acute
onset of hemoptysis have a spesifisc underlying disease process. The most common
identifiable etiologies are Pneumonia, Bronchitis, Pulmonary Tuberculosis, and heart
disesase. All of the children with hemoptysis require a detailed medical history an
physical examination with targeted laoratory and imaging evaluation.

Searching Methode
Investigation was done based on keywords “hemoptysis, Pneumonia, Pulmonary
Bronchiectasis nephrogenic, etiology”. By using limitation of the study in human and
establish within the last 5 years. Founded an article answered the clinical question with
title: Etiologies of Hemoptysis in Children: A Systematic Review of 171 Patients on
Pediatric Pulmonology Journal (2016): 1-5. Authors: Debra R. Simon, MD, Stephen
C. Aronoff, MD, and Michael T. Del Vecchio, MD

30
31